Provider Demographics
NPI:1669738431
Name:SISCO, MELVIN (PA)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:SISCO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 OAK RIDGE TPKE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7100
Mailing Address - Country:US
Mailing Address - Phone:865-483-5678
Mailing Address - Fax:865-483-4027
Practice Address - Street 1:575 OAK RIDGE TPKE
Practice Address - Street 2:SUITE 120
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7100
Practice Address - Country:US
Practice Address - Phone:865-483-5678
Practice Address - Fax:865-483-4027
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1103472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant